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Hip replacement and hip revision

Hip replacement involves replacing a hip joint that has been damaged or worn away, usually by arthritis or injury. Hip revision (or repeat hip replacement) involves replacing an artificial hip joint that has become loose, infected or worn out.

About hip replacement 

Your hip is a ball and socket joint. Normally, the ball at the top of your thigh bone (femur) moves smoothly in the socket of your pelvis (hip) on a lining of cartilage. The cartilage stops the bones from rubbing together. If the cartilage is worn away, the underlying bone is exposed and your joint becomes painful and stiff. As a result walking and moving around becomes painful.

A new hip joint can help to improve your mobility and reduce pain.

Hip replacement

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Types of artificial hip 

Artificial hip parts can be made of metal, ceramic or plastic. Hip joints can be fixed in place using a special substance called 'bone cement'. Alternatively, they may be designed so that your own bone grows onto the metal. These 'uncemented' hips can be coated with a type of bone mineral (hydroxyapatite) or can be made from a material that has lots of tiny holes (porous coating). This encourages your bone to grow into the artificial joint and fix it in place.

What are the alternatives to hip replacement? 

Surgery is usually recommended only if non-surgical treatments, such as taking painkillers (eg paracetamol) or anti-inflammatories (eg ibuprofen), or using physical aids like a walking stick, no longer help to reduce your pain or improve mobility.

Hip resurfacing may be a better option for people with stronger bones. In this operation the surfaces of the ball and socket are covered with metal caps.

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Preparing for your operation 

When you meet the surgeon carrying out your procedure to discuss your care, the details may differ from what is described here as it will be designed to meet your individual needs. Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

They may also have to temporarily stop some of your other medications or change them until your surgery is complete (eg your pain killers may be replaced with ones that do not interfere with the anti-blood clotting drugs that may be given to you for the surgery). You will also be given antibiotics at the time of surgery and for a short period after it to prevent infections.

The operation is usually done under general anaesthesia. This means you will be asleep during the operation. Alternatively you may have the surgery under spinal or epidural anaesthesia. This completely blocks feeling from below your waist and you stay awake during the operation. Your surgeon will advise you which type of anaesthesia is most suitable for you. Often people have a combination; they are asleep during the surgery but have the spinal/epidural anaesthetic as well to ease any pain immediately after the surgery.

If you're having a general anaesthetic, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it's important to follow your anaesthetist's advice.

At the hospital, the nurse may check your heart rate and blood pressure, test your urine and blood, and arrange for x-rays of your knee and/or chest also to check your general health.

Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure.

This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form. You may also be asked to give your consent to have your name on the National Joint Replacement Register, which is used to follow up the safety, durability and effectiveness of joint replacements and implants.

You may be asked to wear a compression stocking on the unaffected leg to help prevent blood clots forming in your veins (deep vein thrombosis, DVT) during the operation. You may need to have an injection of an anti-clotting medicine called heparin as well as, or instead of, stockings.

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About the operation 

A hip replacement usually takes around two hours.

Your surgeon will make a cut (20 to 30 cm long) over your hip and thigh and then separate the ball and socket (hip joint).

They will remove the damaged ball at the top end of your thigh bone (the femoral head) and replace it with an artificial ball. The artificial ball is attached to a stem, which will be inserted into your thigh bone to anchor the ball in place. Your surgeon will then hollow out the hip socket to make a shallow cup and insert an artificial socket into it. The two halves of the hip joint will then be put back together (the ball is put into the socket).

Your surgeon will close the skin cut with stitches or clips and cover it with a dressing.

It may be possible for your surgeon to make a smaller cut over your hip and thigh. This type of operation (minimally invasive hip replacement) is carried out using specially designed surgical instruments. It isn't suitable for everyone – ask your surgeon if it's an option for you.

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What to expect following surgery 

You will need to rest until the effects of the anaesthetic have passed. You may not be able to feel or move your legs for several hours after a spinal or epidural anaesthetic. You may need pain relief to help with any discomfort as the anaesthetic wears off.

A special pillow may be placed between your legs to hold your hip joint still and stop it from dislocating.

A physiotherapist (a health professional who specialises in movement and mobility) will usually visit you each day to guide you through exercises that are designed to help your recovery.

You will stay in hospital until you're able to walk safely with the aid of sticks or crutches. This is usually about five days. However, if you're generally fit and well, your surgeon may suggest you do an accelerated rehabilitation programme, where you start walking on the day of the operation and are discharged within one to three days.

When you're ready to go home, you will need to arrange for someone to drive you.

Your nurse will give you some advice about caring for your hip and a date for a follow-up appointment before you go home.

Most skin stitches or clips will need to be removed after 12 to 14 days. Dissolving skin stitches don't need to be removed.

Recovering from hip replacement surgery 

You will probably need to take anti-clotting medicine for a month or so after surgery, which will be started while you are in hospital. It is important to take the full prescribed treatment course as blood clots may form if the medicines are stopped too early.

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always follow the instructions on the accompanying consumer medicines information leaflet and if you have any questions, ask your doctor or pharmacist for advice.

The exercises recommended by your physiotherapist are a crucial part of your recovery, so it's essential that you continue to do them.

There are certain movements to avoid in the first six weeks after surgery. For example, don't cross your legs or twist your hip inwards and outwards. This is to reduce strain on your scar and to reduce the risk of a dislocation. Your physiotherapist will give you further advice and tips to protect your hip.

You should be able to move around your home and manage stairs. You will find some routine daily activities, such as shopping, difficult for a few weeks and will need to ask for help. You will need to use crutches for about four to six weeks.

You can usually return to light work after about six weeks but if your work involves a lot of standing or lifting, you may need to stay off for longer.

Follow your surgeon's advice about driving as the length of time before you're fit to drive will depend on several factors, including which leg has been operated on and whether your car is automatic.

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What are the risks? 

Hip replacement is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side effects

Side effects are the unwanted but mostly temporary effects that you may experience after having a procedure; for example feeling sick as a result of a general anaesthetic. The main side effects associated with hip replacement surgery are:

  • A sore hip for several weeks
  • Temporary pain and swelling in the thigh and ankle.

Complications

Complications are when problems occur during or after the operation. Most people having hip surgery aren't affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (DVT).

Specific complications of hip replacement are uncommon, but can include the following:

  • Infection – you will be given antibiotics during and after surgery to help prevent this.
  • Joint dislocation – this is most likely to happen immediately after your surgery and you may need another operation to treat this.
  • Difference in leg length – your leg may be slightly shorter or longer and you may need to wear a raised shoe on the shorter side to correct your balance.
  • Hip fracture – tiny cracks can occur in your bone while fitting the new joint. These usually heal, but sometimes the bone can fracture and require further surgery.
  • Unstable joint – the hip joint may become ‘loose’ and you may require further surgery to correct this.
  • Nerve damage – this can quite often result in numbness around your scar, but rarely the sciatic nerve may be stretched and this can leave weakness in the foot (usually temporary).

The exact risks are specific to you and differ for every person, so we haven't included statistics here. Ask your surgeon to explain how these risks apply to you.

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Hip revision surgery 

During your original hip replacement, your hip joint was replaced with artificial hip parts. These usually last from 10 to 20 years, after which they may need replacing.

Renewing an artificial hip joint is more complicated than the original operation because the existing artificial hip joint will need to be taken out before the new one is fitted. If the hip has worn loose then this may not be too difficult for your surgeon, but if it is still bonded to your bone then removing the old components can be a challenge.

You may find that your new joint, although a big improvement on your old joint, may not improve your life as much as your original hip operation. This may be because the muscles can take a long time to recover from the build-up of scar tissue and repeat surgery.

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Further information 

Orthoanswer
www.orthoanswer.org

Australian Orthopaedic Association
www.aoa.org.au

Sources 

American Academy of Orthopaedic Surgeons. Total hip replacement [online]. Rosemont, Ill: American Academy of Orthopaedic Surgeons [Last reviewed December 2011, accessed 21 February 2012]. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=a00377

Arthritis Australia. Joint replacement brochure. [online] Glebe, NSW: Arthritis Australia [Last updated April 2011, accessed 20 February 2012]. Available from: http://www.arthritisaustralia.com.au/Joint_Replacement_brochure.pdf

Bluecross Blueshield Association. Metal-on-metal total hip resurfacing. Tec 2007; 22(5). www.bcbs.com

Guyatt GH Akl EA Crowther M et al. Antithrombotic therapy and prevention of thrombosis (9th edition): American College of Chest Physicians evidence-based clinical Practice Guidelines - Executive summary. [online] Chest. 2012; 141: 2(Suppl. 1S): 1378 – 1412. Accessed 20 February 2012. Available from: http://chestjournal.chestpubs.org/

Khan F Ng l Gonzalez S et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004957. DOI: 10.1002/14651858.CD004957.pub3.

Medical Advisory Secretariat. Physiotherapy rehabilitation after total knee or hip replacement: An evidence-based analysis. Ontario Health Technology Assessment Series 2005; 5(8).

Merck Manuals Online Medical Dictionary. Care of the surgical patient: preoperative evaluation [online] Whitehouse Station, NJ: Merck, Sharp and Dohme Corp. [Last reviewed May 2009, accessed 20 February 2012]. Available from: http://www.merckmanuals.com//preoperative_evaluation.html/knee-surgery

Merck Manuals Online Medical Dictionary. Hip surgery rehabilitation [online] Whitehouse Station, NJ: Merck, Sharp and Dohme Corp. [Last reviewed February 2009, accessed 21 February 2012]. Available from: http://www.merckmanuals.com/professional/special_subjects/rehabilitation/hip_surgery_rehabilitation.html

myDr. Arthritis and surgery: hip replacement. [online] St Leonards, NSW: UBM Medica Australia. 2001 [Last reviewed July 2009, accessed 21 February 2012]. Available from: http://www.mydr.com.au/arthritis/arthritis-and-surgery-hip-replacement

National Institute for Health and Clinical Excellence (NICE). Minimally invasive total hip replacement. [online] Oct 2010 [accessed Feb 2012] Available from: http://publications.nice.org.uk/minimally-invasive-total-hip-replacement-ipg363

National Institute for Health and Clinical Excellence (NICE). Guidance on the use of metal on metal hip resurfacing arthroplasty. [online] 2002. Available from: http://guidance.nice.org.uk/

National Institute for Health and Clinical Excellence (NICE). Guidance on the selection of prostheses for primary total hip replacement. [online] 2000. Available from: http://publications.nice.org.uk/guidance-on-the-selection-of-prostheses-for-primary-total-hip-replacement-ta2

National Prescribing Service. Review of new medicines for people recovering from hip and knee replacements. Media release, April 2010. Surry Hills, NSW: National Prescribing Service Ltd.

Orthoanswer. Total hip replacement [online]. Melbourne: Western Health. [Last reviewed June 2010, accessed 20 February 2012]. Available from: http://orthoanswer.org/hip/total-hip-replacement/definition.html

Orthoanswer. Revision hip replacement [online]. Melbourne: Western Health. [Last reviewed October 2011, accessed 21 February 2012]. Available from: http://orthoanswer.org/hip/revision-hip-replacement/definition.html

Parker MJ Handoll HGH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD000086. DOI: 10.1002/14651858.CD000086.pub2.

Yun AG. Sports after total hip replacement. Clin Sports Med. 2006; 25: 359-64.

Last published: 31 March 2012

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